Provider Demographics
NPI:1437256369
Name:EASTERN SHORE PHARMACY INC
Entity Type:Organization
Organization Name:EASTERN SHORE PHARMACY INC
Other - Org Name:EASTERN SHORE PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:W ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-749-5253
Mailing Address - Street 1:400 EASTERN SHORE DR STE 103
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5513
Mailing Address - Country:US
Mailing Address - Phone:410-749-5253
Mailing Address - Fax:410-749-6345
Practice Address - Street 1:400 EASTERN SHORE DR STE 103
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5513
Practice Address - Country:US
Practice Address - Phone:410-749-5253
Practice Address - Fax:410-749-6345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP022673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2036918OtherPK
MD890101500Medicaid